Provider Demographics
NPI:1396350757
Name:ANDRADE, GALO II (OPTICIAN)
Entity type:Individual
Prefix:
First Name:GALO
Middle Name:
Last Name:ANDRADE
Suffix:II
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 STATE ROUTE 94 S STE 2
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-3664
Mailing Address - Country:US
Mailing Address - Phone:347-581-5135
Mailing Address - Fax:
Practice Address - Street 1:123 STATE ROUTE 94 S STE 2
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-3664
Practice Address - Country:US
Practice Address - Phone:347-581-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY852714314156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY852714314OtherLICENSE